How do I help a teenager who is self-harming?
I spoke about this topic as part of the ‘Let’s All Talk Mental Health’ series in March 2023 and again in March 2024. The below is a summary of my answers during the latter session, along with some clarification and additional resources.
What is self harm?
When I talk about self harm, I’m referring to anything that a young person does with the intention of injuring themselves but not ending their life. In academic literature, this is referred to as non-suicidal self-injury (NSSI), but we should remember that a young person’s intention when they are self-harming may not be clear even to themselves. Self harm could include burning skin, swallowing objects or punching walls, but the most common type of self-harm that I see in my own clinical practice is cutting.
If a young person is self-harming, does it mean that they are also vulnerable to suicidal thoughts and actions?
We know that less than 1% of young people who present to A&E having self-harmed will go on to end their lives by suicide. And those who present to A&E are themselves a very small proportion of the young people we think are self-harming. So although self-harm is certainly a risk factor for suicide, they are not intrinsically linked, and we must be careful of escalating the level of stress a young person is experiencing by responding with panic, or catastrophising. The vast majority of young people who self harm will stop doing so independently by the end of adolescence.
Why is self-harm so common among teens and young people?
It is estimated that around 10-20% of young people will resort to self-harm as a means of coping at some point (estimates vary widely across studies and countries). If you ask young people why they self-harm, they might say things like; ‘I'm punishing myself’, or ‘it just makes me feel better’ or, ‘I don't know’, or ‘I want to turn my mental pain into a physical one’. It is important that we take these responses seriously and see them as meaningful while also recognising that people in distress are often confused about the reasons for their actions, and that these explanations can change even from day to day, or even moment to moment.
I think it is helpful to keep in mind that the basic reason why any young person self-harms is as an attempt to regulate their emotions independently. When our emotions are not regulated, we struggle to make sense of the signals we are receiving from our body, to respond to events flexibly rather than automatically, and to reflect on our experience. Fundamentally, we feel overwhelmed and unsafe. Teenagers are very vulnerable to emotional dysregulation due to an explosion of activity and development in the emotional centres of the brain while the “thinking,” inhibiting regions lag behind. This combination of a tendency to emotional dysregulation and a hardwired desire to begin doing things for themselves rather than relying on adults means that teenagers are particularly vulnerable to self-harm as a means of coping.
Teens tend to self-harm because they find it works. When they are feeling low, flat or numb, the pain of cutting may help them to “feel something”. When they are highly stressed or anxious, it can release endogenous opioids, the body’s natural painkillers, that have a calming effect. In both cases, teenagers are using self harm to move themselves back into the “window of tolerance” - a state of emotional balance in which their feelings and lives make sense.
None of this is to say that we should view self harm in teenagers as normal or unconcerning. In many cases it is clearly a very risky coping mechanism and one that does not help them learn skills to solve the problems they face, whether those skills are individual or interpersonal. We must take action to keep our children safe and turn them towards healthier ways of coping with their feelings, including using others as a resource.
A related and equally important question is why teens seem to have become even more vulnerable to self harm in the period since 2010: UK medical records indicate a 78% increase among 13-16 year girls and a 134% increase among boys. If you’re interested in this question, I’d highly recommend Jonathan Haidt’s new book, ‘The Anxious Generation’.
How does teenage self-harm start, progress and develop?
I think it is a common worry among parents that young people are passing knowledge of self harm among themselves, or even “egging each other on” to try it, but the young people I work with are horrified by this idea. They tell me that no one specifically told them about self-harm; rather, they picked it up on its existence as a way of coping from TV shows, news and social media. It seeped into their consciousness over time before they reached the point of thinking to do it themselves. This might represent a major change from the experience of millennial or Gen X parents, for whom mental health and related topics were not so much “out there” in the media when we were young.
The course of self harm seems to vary significantly by gender. Research has shown that self harm is more than twice as common in girls, in whom it begins in the early teenage years, peaks around 16-17, and tails off through their twenties. (Some girls tell me that self harm began earlier, with the onset of puberty, and as most studies do not include children below the age of about 12 this may not be captured in the literature.) In boys, self harm seems to peak first in the early teenage years, but then rise again in the early twenties before falling gradually.
Of course, these ages refer to groups rather than individuals, and a young person’s journey with self harm will depend on the stressors they face and whether/when they receive help. In my experience, the GCSE years are a major flashpoint, and young people often stop self harming very quickly once they receive appropriate support. Ultimately, less than 1% of people seem to be self-harming by the time they are in their 30’s.
Most young people who self-harm will move on from this behaviour once the big stresses of adolescence ease and their developing brain supports better regulation of their emotions. It is important for adolescents and their parents to hold on to the fact that this period of development is an extremely difficult time in life, but it is going to pass.
Should parents be talking to their children about difficult emotions and about self-harm? And what might they say?
You could certainly be forgiven for worrying that raising the topic of self harm with your teen will put the idea into their head, but this is highly unlikely to be the case. First, as above, teens are very likely to have heard about self-harm prior to your conversation with them from media or peers. They may be curious about it, know friends who have done it, or even have tried it themselves. In all these cases, having an appropriately concerned adult available to talk about it can provide a vital sounding board and route to support if needed. As with suicide, studies show that asking young people about these behaviours does not make them more likely to engage in them. More broadly, we should always be talking about, validating and normalising difficult emotions with our children. We have over 100 years of theory and research showing us that the ability to talk about our feelings, especially to those we are close to, is a vitally important predictor of future wellbeing.
As parents, we should think preventatively and decide what is the appropriate age to open up a conversation about self-harm with our child. When the time comes, as with any difficult conversation, it's our job to put the subject on the table - not to force it, but to make it clear that self-harm is okay to talk about, and to give permission to come back to the conversation whenever needed.
Here are some suggestions surrounding these conversations with kids aged 10+.
Be curious. Expressing persistent and genuine curiosity about your child’s life instils a sense that you're an adult who can be trusted and has information or advice that might be valuable. This dynamic lays the groundwork for your child to come back to you with tough topics in the future.
Acknowledge the difficulty of life and share healthy coping strategies. This is about normalising struggle and negative emotions and letting them know they are not alone.
“You know, this thing that you're going through at the moment seems really difficult. How are you dealing with that? When I am feeling worried, stressed or sad, this is what I do to help myself out…”
And then, once you get into the teenage years, these conversations may look more like:
Understanding what they know about self-harm. Being aware of what your teen already knows will help you to have more meaningful conversations with them on the subject.
“I heard that some people your age might hurt themselves to manage big emotions. Is that something that you've heard about? Do people around you tell you that they're doing it, or have you even done it yourself?”
Look for opportunities to raise the conversation about self-harm. If you're watching TV together, see something on social media, hear something on the radio in the car, seize those moments to show some curiosity about their experience.
Steer clear of judgemental, negative responses to self-harm. Expressing that you think self-harming is “disgusting”, “stupid”, “pathetic”, “childish” or “selfish”, for example, needs to be avoided. Though the thought of our child harming themselves might provoke powerful responses in us as parents, it’s important that these reactions don’t make it more difficult for them come back to us in the future to ask for help.
Let them know that they can always come to you. Be clear and ensure your teens know that they can come to you to talk, for advice or even to share concerns about other people.
Value and prize the sharing of difficulties within your family. Parents can help teens to develop a sense that sharing and managing emotions is something that's not only positive but is prized and valuable within your family. Let them know that whatever their emotions are, there is nothing that can’t be understood and managed together.
Express a firm determination to keep them safe. Though teenagers want to go it alone, take risks and be their own person, they also need to know that they have a safe base from which to do that. See more thoughts on managing the risk of self harm below.
“If this (self-harm) is something that's happening for you or around you, I want to hear about it. I love you and I want to keep you safe. Tell me what you need from me so I am able to do that.”
Start afresh if things haven’t worked so well in the past. It's never too late to reset and start to have some open conversations with your teen. Acknowledge the past and move on to more open communication.
“I recognise that I might not always respond helpfully because I feel upset or sad about what's happening, but I really want to hear what it's like for you.”
Being able to have conversation about tough topics with teens comes down to parents being there to ask open questions, give judgement-free responses and leave the door open for more.
What should parents do if they find out that teens are harming themselves?
It's important that you follow your instincts. If you think that something might be going on, then ask about it or seek external support. Safety has to be paramount in any self-harm situation.
Restrict access to the means of young people self-harming. If, for example, you have a young person who's cutting, then it would be advised that you remove the items they may use to harm themselves e.g. lock away the kitchen knives in the boot of the car, or keep their razor somewhere safe and give it back to them when they need it for shaving. Removing such items puts a motivational barrier between them and the act. Yes, they may be able to find a way around such restrictions, but by the time they have done that, the urge may have passed. The other reason for doing this is that it signals a clear intent that you've heard the message that they are in distress and you are determined to keep them safe, and that in itself is helpful.
“I'm worried about you, and I'd like you to come to me next time you’re feeling upset. I've made it safer for you by putting these things elsewhere. I want there to be a moment where maybe you could come to me. It’s not because I’m angry or want to make life harder for you.”
Create a safety plan. A safety plan is an evidence-based practical tool aimed at reducing the risk of a person harming themselves by identifying helpful strategies and resources in advance. Supporting your child to make one again signals the intention to understand what is going on, to keep them safe, and that they can come to you when they need to. You can find a free downloadable template here.
Don’t keep the risk to yourself. In order to support your child, you need to be well-supported yourself. Having people around us who understand what we are going through lowers our levels of stress and helps us keep online the parts of the brain necessary for understanding and helping our children. It may take bravery, but letting people you trust know what you are dealing with builds a safety net for you and your child. You should also share information, and your safety plan if possible, with anyone else who might need to take action to reduce the young person’s distress or keep them safe. This includes co-parents, school staff or community leaders.
Can professional help make a difference?
Yes, and the advice in this article isn’t a substitute for support tailored to your situation. A good therapist is skilled in using conversation and non-verbal cues to bring young people to the edge of their “window of tolerance” but remain safely within it. They will also help teens to notice and build knowledge of states of mind that can be difficult and uncontrollable. Over time and repeated occurrences, this builds useful “implicit" memories (you can think of them as scripts or computer programs) that will allow them to successfully regulate their own emotions when under stress.
If you are concerned that your support is not enough to help your teen with their difficult feelings or risky behaviour, consider involving a professional. Speaking to their GP is usually a good first step. You can find a blog post here on different types of mental health professionals you may encounter privately and how they can help.
Let’s All Talk Mental Health host Q&As with experts in all sorts of topics. Check out their calendar for relevant topics to you and your family.